How to treat Suboxone (buprenorphine) addiction?

From the Guidelines

Treating Suboxone (buprenorphine) addiction requires a comprehensive approach involving medical supervision and behavioral support, with the most effective treatment typically involving a gradual taper of buprenorphine under medical supervision. This approach is supported by the fact that brief treatment periods with rapid medication tapers are associated with high rates of relapse, therefore, longer-term or maintenance treatment is generally indicated for patients with opioid dependence, as noted in a study published in the American Family Physician in 2013 1.

The tapering process should be individualized, with a reduction in dose by 10-25% every 1-2 weeks, depending on the patient's response. For example, someone on 16mg daily might reduce to 14mg, then 12mg, and so on until reaching a low dose (2mg or less) before final discontinuation. During this process, withdrawal symptoms can be managed with supportive medications like clonidine (0.1-0.2mg every 6 hours as needed) for blood pressure and anxiety, loperamide for gastrointestinal symptoms, and non-narcotic pain relievers.

Key aspects of the treatment plan include:

• Gradual taper of buprenorphine to minimize withdrawal symptoms
• Medical supervision to adjust the taper plan based on individual response
• Behavioral support through counseling, cognitive behavioral therapy, and support groups to address psychological dependence
• Management of withdrawal symptoms with supportive medications
• Consideration of naltrexone after detoxification to prevent relapse, as part of a comprehensive treatment plan to improve outcomes and reduce the risk of relapse.

The use of buprenorphine/naloxone (Suboxone) is preferred due to its safety feature that prevents misuse by crushing and injecting the combined product, as the naloxone component is poorly absorbed via the sublingual route 1. Regular medical monitoring is essential throughout the treatment process to ensure safety and adjust the plan as needed.

From the FDA Drug Label

Addiction, Abuse, and Misuse Inform patients that the use of buprenorphine hydrochloride, even when taken as recommended, can result in addiction, abuse, and misuse, which can lead to overdose or death [see WARNINGS] Although the risk of addiction in any individual is unknown, it can occur in patients appropriately prescribed buprenorphine hydrochloride Addiction can occur at recommended doses and if the drug is misused or abused.

The treatment of Suboxone (buprenorphine) addiction is not directly addressed in the provided drug labels.

• Key points to consider when treating addiction:
  • Assess each patient's risk for opioid addiction, abuse, or misuse prior to prescribing buprenorphine hydrochloride.
  • Risks are increased in patients with a personal or family history of substance abuse (including drug or alcohol addiction or abuse) or mental illness (e.g., major depression).
  • Patients at increased risk may be prescribed opioids such as buprenorphine hydrochloride, but use in such patients necessitates intensive counseling about the risks and proper use of buprenorphine hydrochloride along with frequent reevaluation for signs of addiction, abuse, and misuse. However, the FDA drug label does not provide specific guidance on how to treat Suboxone addiction. 2 2

From the Research

Treatment Options for Suboxone Addiction

• Medication-assisted treatment (MAT) is a common approach for treating opioid use disorder, including Suboxone addiction 3, 4, 5.
• Buprenorphine, the active ingredient in Suboxone, can be used to treat opioid use disorder, but it can also be addictive 3, 5.
• Methadone and naltrexone are other medications that can be used to treat opioid use disorder, but they have different mechanisms of action and potential side effects 3.

Behavioral Counseling

• Behavioral counseling is an important component of treatment for opioid use disorder, including Suboxone addiction 6.
• Counseling can help patients develop coping skills and prevent relapse, and can be tailored to individual needs and circumstances 6.
• Studies have shown that behavioral counseling can improve treatment outcomes and reduce the risk of relapse 6, 7.

Medication-Assisted Treatment

• Medication-assisted treatment with buprenorphine can be effective for treating opioid use disorder, including Suboxone addiction 3, 4, 5, 7.
• Buprenorphine has a ceiling effect that limits respiratory depression and adds to its safety in accidental or intentional overdose 7.
• Family physicians can obtain a waiver to prescribe buprenorphine for medication-assisted treatment, and follow-up visits should include documentation of treatment progress and potential relapses 7.

Barriers to Treatment

• Access to treatment for opioid use disorder, including Suboxone addiction, can be limited by lack of access to healthcare services and stigma surrounding addiction 3, 4.
• Poor adherence to treatment recommendations and high rates of relapse and overdose after leaving treatment are also significant challenges 3.
• New formulations of buprenorphine and naltrexone, such as depot and implant formulations, may help address issues of safety and adherence 3, 5.